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Patent Ductus Arteriosus

more about Patent Ductus Arteriosus


PDA



  • In this condition, a tunnel of tissue between 2 large arteries in the chest (which is supposed to close after the baby is born) remains open.  The name of the tunnel is ductus arteriosus, so if it remains patent (open), this is called a patent ductus arteriosus.
  • In the commonest variety of PDA, blood (which has already passed through the lungs and all 4 chambers of the heart) then goes down the PDA (the open tunnel to the lungs; i.e., the tunnel that should close off) and back to the left side of the heart again.  This overloads the left ventricle (the heart chamber that has to push blood out of the heart to the various organs).
  • As the left ventricle becomes overloaded with blood, the blood backs-up and eventually causes all 4 chambers of the heart to be overloaded with excess blood to eject.  Like a water balloon, the heart chambers expand when more and more blood is presented to them that they cannot eject right away.

  • This discussion combines the features of several PDA's in order to show what the PDA symptoms might be, but a lot of PDA's have minimal symptoms and no abnormality on chest X-ray or electrocardiogram.
  • In a simple PDA, the blood is going down the tunnel from the aorta to the pulmonary artery, and then to the lungs; and the lungs have not yet been damaged by the increased blood flow.  The symptoms are as follows:
    1. The baby has a loud heart murmur (a noise in the heart) over the upper chest, near the neck. 
    2. The murmur sounds a little like waves or rapids (sounds of turbulence), rather than 1 smooth or musical noise, and it may be a long-lasting noise rather than a brief one. 
    3. There is a wide difference between the systolic and diastolic blood pressure.  That is, the left ventricle squeezes, creating the highest blood pressure that we will find during a heartbeat, and then the left ventricle relaxes, creating the lowest blood pressure that we will find during a heartbeat.  Because there is a lot of run-off down into this tunnel (the PDA), the pressure in the pipes (arteries) is not maintained at a high level, and there is a low pressure when the left ventricle relaxes before its next squeeze.
    4. The baby does not have central cyanosis (does not turn blue in the lips) even though there is heart disease with a loud Heart Murmur.  The baby develops fast breathing and tires very easily because too much blood is flowing to the lungs, increasing the work of breathing. 
    5. Too much blood is also circulating through the heart, going around and around through the PDA.  Congestive heart failure eventually develops in a large PDA (shortness of breath, rapid heart rate, enlargement of at least some of the chambers of the heart, noises in the lungs from the excess fluid in the lungs).
  • Symptoms and heart murmur are usually not noticed in the newborn nursery because the new baby still retains some features of the fetal heart and lungs, in which a PDA does not cause any difficulty.
  • In the connections between the fetal heart and lungs, the tiny lung arteries are so tightly coiled that blood flowing down a PDA meets a lot of resistance when it tries to flow to the lungs, and very little blood flows down the open PDA in the first few days or weeks.
  • When the mother takes the PDA baby home, she might feel or see a great deal of chest movement, due to increased blood flow down the PDA tunnel into the now-open lung arteries.  Technically, this is called a left-to-right shunt because blood that has already passed through the left side of the heart (left ventricle) goes down the PDA tunnel; and then to the lungs (which normally only receive blood from the right side of the heart).

  • Unknown

  • Diagnosis of a large PDA:
    1. The loud murmur over the upper chest, coupled with the sounds of turbulent flow, suggests PDA.  The baby 's electrocardiogram shows that heart chambers are enlarged.  The chest X-ray shows excessive blood is passing through the lungs, because blood from the aorta is passing down the PDA tunnel to the pulmonary artery (and from there, the excess blood goes to the lungs).  The pulmonary artery size is increased.  This can be seen on the ordinary chest X-ray of the baby.
    2. An echocardiogram of the heart (ultrasound of the heart) might show the enlarged left ventricle, the blood flow through the PDA, and the high pressure in the pulmonary artery when it receives this high-pressure blood from the aorta.
    3. The important features of a large PDA are: (a) possible history of German measles in pregnancy, (b) pulses are very prominent because of the big difference between systolic and diastolic blood pressure, (c) usually a Heart Murmur starting in infancy, (d) chest X-ray may show increased fluid in the lungs and an increased size of the pulmonary artery, and (e) congestive heart failure may develop.

  • Birth at a high altitude
  • Mother had rubella (German measles; also known as 3-day measles) during the first 3 months of this pregnancy
  • Female infant
  • Prematurity

  • Oxygen, if needed; respirator if needed
  • Limited fluid intake if congestive heart failure. Diuretics if congestive heart failure.
  • 4 methods of closing the PDA, if it does not close naturally:
    1. Anti-inflammatory medicine (indomethacin) might be used to close the PDA in an infant.  Indomethacin is more useful in premature infants than in full term infants.
    2. Surgery with a chest incision (thoracotomy) in the left underarm area: the tunnel of tissue that connects the aorta to the pulmonary artery is tied-off.  If the PDA is large, it is likely that surgery will be used.
    3. Catheter procedure: the PDA is closed non-surgically by a procedure that blocks the opening of the PDA with a metal piece, inserted through a catheter (transcatheter closure).  If the PDA is small but needs closing, it is likely that the catheter procedure will be used.  A Gianturco steel coil is a device commonly inserted through the catheter, to fill the PDA opening.  After the coil is inserted, it unwinds to an expanded size, blocking blood flow through the PDA.  In many infants, several coils need to be inserted to block the PDA completely.  Some other devices commonly used in other countries to block the PDA are on "investigational status" in the United States, not approved by the Food and Drug Administration for routine use.
    4. Video assisted thoracoscopic surgery (VATS): This is minimally-invasive surgery.  Small instruments and a video display are inserted through small incisions in the chest, and a stainless steel clip is placed across the PDA, blocking it off.  This reduces the likelihood of Scoliosis which might occur with the large chest incision of a thoracotomy.

  • Congestive heart failure
  • Bacterial endocarditis (bacterial infection of the heart valves)
  • Aneurysm (a bulge in the wall of an artery)
  • Pulmonary hypertension (excessive pressure in the tiny arteries of the lungs)
  • Scoliosis (curvature of the spine), chest deformity, or ribs that do not move properly, may occur in later years, if an infant has chest surgery (open thoracotomy) to close the PDA.
  • If the ribs do not move properly, this may cause some breathing difficulty.
  • The metal coil can break loose from its position in the PDA, and cause an embolus ( a blockage of an artery in the lungs or a blockage of an artery in a vital organ ).
  • Injury to the femoral artery or vein in the groin can occur, while threading the catheter into the body to reach the PDA.
  • Accidental Injury to nerves in the chest
  • Failure of the PDA to close completely

  • Babies who had no Heart Murmur in the newborn nursery but have a Heart Murmur at the first well-baby checkup might have a PDA.
  • Mothers who feel or see vibration in the infant's chest might suspect a PDA.
  • Infants who were previously well and then start having shortness of breath or rapid heartbeat might have a PDA.  Bring all these concerns to the attention of your physician at the earliest possible moment, since heart failure might develop from a PDA.

  • Other Congenital Heart Diseases which might make a baby ill, but do not usually produce blatant cyanosis of the lips are as follows: (1) Atrial Septal Defect, secundum type; (2) ventricular septal defect; (3) pulmonary valve stenosis.




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